The MacArthur foundation depression education program for primary care physicians: background, participant's workbook, and facilitator's guide

ELSEVIER

Special Section

The MacArthur Foundation Depression Education Program for Primary Care Physicians: Background, Participant's Workbook, and Facilitator's Guide ~

Steven Cole, M.D., Mary Raju, R.N., M.S.N., F.N.P., James Barrett, M.D., Martha Gerrity, M.D., Ph.D., Allen Dietrich, M.D.

Steven Cole, M.D. Professor of Psychia t ry Alber t Eins te in Col lege of Medic ine Nor th S h o r e - L o n g I s l and Jewish H e a l t h Sys tem,

and Vice-Pres ident and Medica l Direc tor Care M a n a g e m e n t G r o u p of Grea te r N e w York,

Inc.

M a r y Raju, R.N., M.S.N., F.N.P. Director , Educat ional D e v e l o p m e n t The MacAr thu r Founda t ion D e p r e s s i o n

Educat ion Project

James Barrett, M.D. Professor of Psychia t ry D a r t m o u t h School of Medic ine

Mar tha Gerr i ty , M.D., Ph.D. Ass is tan t Professor of Medic ine Oregon Hea l t h Science Univers i ty

Al len Dietr ich, M.D. Professor of Fami ly Medic ine D a r t m o u t h School of Medic ine

1 The development of this material and related programs was made possible, in part, by grants from The John D. and Catherine T. MacArthur Foundation, Abbott Laboratories, Bristol-Myers Squibb, Forest Laboratories, Inc., Pharmacia & Upjohn, Pfizer, and Smith- Kline Beecham. Earlier versions were published © The John D. and Catherine T. MacArthur Foundation, 1998. Publication of this revised material is made possible with permission of the MacArthur Foundation Initiative on Depression and Primary Care.

General Hospital Psychiatry 22, 299-358, 2000 © 2000 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York NY 10010

299 ISSN 0163-8343/00/S-see front matter

S. Cole et al.

A b s t r a c t

In order to improve the assessment and management of depression in general medical care, the John D. and Catherine T. MacArthur Foundation supported the development, evaluation, and dissemination of an eight-hour depression education program (DEP) for primary care physicians. This publication includes a paper describing the background and educational rationale for the program structure, the complete participant's workbook, and a facilitator's guide for teaching the program. Given in two separate four-hour workshops by a psychiatrist and a primary care physician, DEP is delivered to small groups of learners (about 12) using an interactive adult learning model and multiple teaching techniques including targeted yet flexible objectives, two lectures, videotape demonstration and discussion, role-play exercises, a focused monograph on depression, an interview checklist, structured assessment and outcomes tools, clinical case studies, and audiotape review of actual patient interviews. DEP has been shown in a prospective randomized trial to improve physicians" interviewing skills as well as simulated-patient satisfaction scores. Over 150 PCPs in four states have taken DEP in more than 30 separate programs given by 24 trained facilitators. Participants, despite a wide diversity of background knowledge and skills, have uniformly reported remarkably positive learner satisfaction with all dimensions of the Program.

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The MacArthur Foundation Depression Education Program for Primary Care Physicians

The MacArthur Foundation Depression Education Program for Primary Care Physicians: Background and Rationale

Overview

This publication presents the MacArthur Founda- tion Depression Education Program for Primary Care Physicians (DEP). It includes three elements: 1) a background paper reviewing the purpose, rationale, and current status of DEP; 2) the Partici- pant's Workbook; 3) and the Facilitator's Teaching Guide.

Developed under the auspices of the John D. and Catherine T. MacArthur Foundation Initiative on Depression in Primary Care, DEP is a complex,

eight-hour training program for primary care physicians (PCPs). Originally developed in 1995, DEP has undergone a series of pilot demonstrations, tests of efficacy, and subsequent revisions through input from 15 primary care physicians, psychiatrists, and educational consultants. This version represents the culmination of these collaborative efforts.

In addition to the background paper, this publication includes a Participant's Workbook and a Fa- cilitator's Guide. The Workbook includes 16 specific learning objectives, hard copy of two slide- lectures, a comprehensive monograph written specifically for this Program, an interview-training checklist, structure role-play guidelines and exercises, a depression tool-kit designed for clinical use, and instructions for audiotaping and reviewing interviews with patients.

The Facilitator's Guide presents detailed information on teaching methods and educational approaches for each segment of the eight-hour program. The MacArthur Foundation Initiative on Depression in Primary Care has already delivered separate facilitator-training programs in New York and Oregon and additional programs are antici- pated in the future. 2 While teachers who would like

2 For further information, contact Allen Dietrich, M.D., Chair, The MacArthur Foundation Initiative on Depression in Primary

to use these materials are encouraged to participate in a facilitator-training program, the Guide is included here to offer some direction to educators who may desire to implement part of the Program on their own.

While the DEP itself is copyright protected, the intention of the MacArthur Foundation has always been to make the material broadly accessible in the public domain as a public health service. As a cour- tesy to assist in its evaluation efforts, however, the Initiative requests that individuals choosing to utilize these teaching materials inform the Initiative when and how these materials are used. 2

Rationale for the Program

Depression is now widely regarded as a major public health problem [1]. Epidemiological findings indicate that 5--10% of the population suffers from major depression or chronic depression (dysthymia) and that at least 10-15% of primary care patients experience depressive disorders [2]. Numer- ous studies document that 30-70% of these depressive disorders are missed by primary care physicians (PCPs). Even when these disorders are recognized and pharmacologically treated in primary care, fewer than 50% of patients receive adequate doses or duration of antidepressant treatment [3]. In one large study, 30% of patients had stopped their medication within the first month of treatment and 44% had stopped within the first three months of treatment [4]. One year follow-up of patients treated by their PCPs for major depression indicates that more than 50% remain depressed [5,6].

Under-recognition and undertreatment of depression becomes even more noteworthy in the light of increasing evidence that depression is a

Care, Depart~nent of Family Medicine Dartmouth Medical Cen- ter, Hanover, NH.

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disabling and costly condition. Direct treatment costs approximate $12 billion/year while costs of lost productivity due to depressive disorders approach $31 billion (in 1990 dollars) [7]. Conse- quently, depression incurs the same economic cost to society as heart disease. WHO predicts that major depression will be one of the two most disabling conditions worldwide in the 21 ~t century [1]. Depres- sion stands as the leading cause of short-term disability in the workplace and is associated with more impairment in social and physical functioning than most other chronic general medical conditions [8].

Some observers have argued that PCPs are more skilled at recognizing and treating depression than the above data suggest. PCPs may, in fact, recog- nize that patients may be depressed, or at least emotionally distressed, but do not "diagnose" the condition because of resistance of patients, stigma, and administrative barriers such as lack of payment to PCPs for managing psychiatric~ disorders [9]. Moreover, some studies indicate that PCPs are better at recognizing and initiating treatment of the depressive conditions that are more serious (associated with more impairment) than the ones that may spontaneously remit [10]. Despite these findings, outcome studies still indicate that depressive conditions in primary care do not remit as often as they could with more systematic and rigorous treatment interventions [11].

Under the direction of Robert Rose MD, the John D. and Catherine T. MacArthur Foundation took cognizance of these data in 1994 and launched a multi-faceted initiative designed to improve the assessment, management, and outcome of depression in primary care. Three projects were initially fund- ed: a national study of the current practices of PCPs in the treatment of depression; a randomized, prospective trial of a selective serotonin reuptake inhibitor (SSRI) vs problem-solving therapy for minor depression in primary care; and the development and evaluation of a depression education program for PCPs. This paper discusses the educational rationale for the training program that was developed, describes the program in detail, and reports the subjective evaluations of the first 150 PCPs who have already taken the training. Another paper presents the results of a randomized, prospective educational efficacy trial [12].

Educat iona l Rat iona le

The MacArthur Foundation charge to the authors centered on the need to create an intervention tool

that was broad enough in scope to be acceptable to diverse PCPs across the country and that would also be sufficiently effective to measurably improve PCPs' competence in the assessment and management of depression. Systematic literature reviews and scientific advisory panels were unable to locate any previous such programs that had been subjected to reasonable scientific scrutiny.

In the absence of previous studies to guide this work, the authors reviewed the literature on depression in primary care and the literature on barriers to effective assessment and treatment in primary care. Major educational obstacles seemed to center on both knowledge as well as skills deficits. That is, effective management of depression in primary care would require not only improved knowledge of depression (e.g., diagnostic criteria, pharmacological strategies) but also improved physician-patient communication skills. Such communication skills are necessary to detect and evaluate abnormal mood, to overcome the patient's resistance to the diagnosis, and to develop a therapeutic alliance to maximize adherence and outcome.

Thus, the educational task required the development of both knowledge and skills. The authors adhered themselves to educational principles in de- signing an effective program to meet the goals of the initiative. The objectives of training should be focused and clear; teaching methods should be appropriate to the educational domain of the objectives (i.e., knowledge, skills, or attitudes); and evaluation strategies should be congruent with the objectives and teaching methods [13]. Since the MacArthur Foundation also desired to disseminate the program widely, every attempt was made to keep the training program as brief and as inexpensive as possible.

The development of a brief and inexpensive training program designed to meet'the knowledge objectives was not difficult. Knowledge can be increased through lectures, reading, videotapes, computer programs, and so on. Information necessary for PCPs to master could be collected, organized and disseminated rather easily.

The core challenge of the educational design, however, rested in the development of a program adequate to improve the communication skills of the participating physicians. Previous research clearly indicated that communication skills play a key role in effective diagnosis and treatment of chronic conditions (including depression) in primary care [14-17]. Furthermore, research also indicated that communication skills related to assess-

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ment and management are teachable [18]. Unfortunately, previous research also suggested that the mastery of effective communication skills requires time and dedicated small group instruction, emphasizing skills-development educational methods, e.g., demonstration videotapes, role-play practice, feedback and re-practice [19].

To our knowledge, no previous communication- skills training programs have been developed and tested specifically for depression in primary care. However, many related interviewing programs have been subjected to scientific scrutiny. A review of programs of 30 h or longer indicated positive results [20]. Levinson's study compared a 4-h program to a week-long program, demonstrating that the 4-h program was not effective for changing behaviors, but that the week-long program was effective [19].

The shortest effective training program that the authors could locate was Roter's 8-h program designed to improve PCPs" ability to detect psychiatric disorders in primary care. In this model, small groups of PCPs met for two 4-h workshops, sepa- rated by a 2-week interval during which time participants were expected to practice the skills they learned in workshop one. During the 2-week intersession, participants were also expected to tape record at least one patient and review the audiotape before bringing it to review with facilitators and peers in session two. Teaching methods included didactics, but major emphasis was placed on skills practice with feedback (role-play). The program was successful in improving PCPs interviewing skills and diagnostic abilities, as well as improving patients' emotional outcome six months later, compared to patients of the control physicians [18].

Since the Roter program was the shortest and only training program the authors could find that had successfully improved communication skills of PCPs, the skills-training segment of the depression educati6n program was modeled on this paradigm.

Program Design The MacArthur Foundation Depression Education Program for Primary Care Physicians (DEP) is an 8-h program divided into two 4-.h workshops, sep- arated in time by a 2-week interval between session one and session two. The program is designed to be given to small groups of 12 PCPs at a time, facili- tated by a team of a primary care physician and a psychiatrist. Small groups are necessary to maxi- mizerinteractive learning, as welt a s t o permit prac-

tice of skills with feedback, the essential: teaching method for improving skills. The team teaching creates a conscious model of ideal cooperation and collaboration between a PCP and a psychiatrist, while it also preserves a facilitator/learner ratio of 6:1 that permits effective individual feedback.

The program is designed to meet 16 specified objectives: 6 knowledge objectives and 10 skills objectives. The program utilizes a variety of teaching methods consciously directed at meeting these objectives: learner-centered goal-setting, review of objectives, interactive lectures, review and discussion of demonstration videotapes, review and discussion of audiotapes of actual patients, and role-play practice with feedback.

Session one begins with a learner-centered exercise that sets the tone for the program. At the start of the first workshop, participants are asked to write down three personal learning objectives. In the first 30 min of the program, facilitators encourage personal introductions and review of these personal objectives. Learners' personal objectives are compared with the 16 original objectives of the program. The objectives are usually remarkably similar to the original workshop objectives, but when particular aspects may differ in focus or emphasis, participants and facilitators together can make decisions regarding how to tailor the teaching materials to the personal objectives of the learners. This exercise draws on the educational value of learner-centered (or "adult" learning) methodology. It also allows facilitators to learn enough about the expertise and interest of the participants to gear the presentation to the knowledge, skill, and interest level of the learners.

Following this exercise, the psychiatrist facilitator presents an interactive lecture with 36 slides cover- ing the following topics: a brief review of the prevalence, significance, and diagnosis of depression in primary care; barriers to improved care; the communication skills that can improve assessment and management; and management guidelines. The lecture is interactive in design and there are scheduled pauses for discussion. The lecture with discussion is designed to take about 1 h and 15 min.

After the interactive lecture, the facilitators present the "Depression Interview Checklist," which is an educational device created to focus learners on the 10 specific communication skills objectives emphasized in this program. Usually the primary care physician presents this tool. The instrument and skills associated with the instrument are reviewed. A 15-min demonstration videotape is

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then shown. The tape represents a simulation of a diabetic patient who is non-adherent to medication, who presents with a new symptom of abdominal pain and who also has covert depressive symptomatology. The PCP on the videotape simulation ad- dresses all 10 communication objectives of the program [cf. Section 1 (p. 310) of the workbook].

Because it was educationally important to demonstrate all 10 communication skills on the videotape, the running time of the interview is intended to be longer than a real-life primary care interview. In actual primary care practice, the PCP will flexi- bly utilize the interviewing skills demonstrated depending upon the needs of the situation. The purpose of the videotape is clarified for the participants, to be sure that they are aware that the design of the demonstration video is to present new communication behaviors and not necessarily to demonstrate a pragmatic focused primary care visit.

After a discussion of the patient scenario and the skills the PCP used on the videotape, facilitators guide the participants in a model role-play exercise to practice the skills demonstrated on the videotape. A skills-practice mnemonic, "SPAR," is introduced to structure role-play exercises more efficiently (cf. Section 5, p. 326). "S" stands for script the role-players; "P" stands for practice; "A" stands for assessment (feedback); and "R" stands for repeat the exercise after feedback. After the model role-play exercise, participants then break up into groups of two (a "doctor" and a "patient") to practice skills on a more intensive level. The two facilitators circulate among the small groups to monitor group process, give additional feedback and encourage continued practice and re-practice of specific skills.

The focus of the program centers on actual prac 7 tice of new behaviors. Skills and new behaviors cannot be mastered through discussion alone. The guiding principle of the educational program is that skills must be practiced to be learned. Thus, facilitators continually balance the need to practice skills with the need to allow participants to reflect on what they are learning.

Session one ends with a facilitator's review of the activities of the day, a facilitator's summary of the learning that occurred and instructions for the 2-week intersession experience. Learners are encouraged to read (or re-read) the monograph on assessment and management of depression that was prepared especially for this program, to practice the new skills with their patients and to obtain at least one audio-tape of an actual patient encoun-

ter. Ideally, this audiotape should be obtained during an interview with a distressed, possibly depressed patient. Alternatives for audiotaping include any problematic patient or any patient at all. PCPs are asked to review the audiotapes on their own time and select one five-minute segment to bring to workshop two for review with facilitators and peers.

Assessment and outcomes monitoring tools (cf. Section 7, p. 328) are also presented for PCPs to use in their practices as they desire. At the end of session one, participants complete a detailed evaluation form that covers numerous general and specific aspects of the program. In particular, the evaluation form asks participants to rate the effectiveness of the program in meeting each of the individual 16 specified program objectives.

Workshop two begins with a general discussion of the intersession experience. Participants have the opportunity to discuss their experiences with new interviewing behaviors, and facilitators can use this information to help guide the rest of the workshop. Participants are also encouraged to re-state or mod- ify their original learning objectives in order to help facilitators address any new changing needs in session two.

Thirty minutes of session two are then devoted to reviewing the specific evaluations the participants themselves completed concerning session one. Gen- eral comments and suggestions are shared with the group, especially ones that could shape session two to more effectively meet learners' needs. In addition, participants' ratings of the extent to which each of the individual objectives have been met are also shared with the group. Facilitators then have the opportunity to offer specific information that can be used to fulfill unmet learning objectives or plan the rest of session two accordingly.

The next segment of workshop two is devoted to presentation and review of audiotapes, with role- play practice of problematic situations utilizing communication skills emphasized in the program. The initial review occurs in the group as a whole, to demonstrate the recommended procedure for presentation, review, and role-play practice. After this initial presentation, the rest of the audiotape reviews occur in small groups of three, with the f a - cilitators circulating among the groups to assist in group process, delivery of feedback and role-play practice.

A more detailed psychopharmacology mini- lecture is presented, expanding on the general information included in the lecture in the first work-

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shop, to review practical antidepressant strategies for primary care. Emphasis is placed on management of treatment-emergent side effects, drug interactions, and pharmacological strategies for patients who demonstrate partial response to treatment. Psychopharmacology case management problems are also presented and discussed (cf. Sec- tion 9, p. 334).

The concluding segment of the program involves group review and discussion of lessons learned from the program as a whole. Participants have the opportunity to review their learning and ask final questions. The facilitators review their experiences of the workshops and summarize key learning principles and objectives. Participants are encouraged to discuss their plans for clinical care and identify future learning objectives with respect to depression and /or communication skills.

Evaluat ions

By the fall of 1999, approximately 150 PCPs in four states (New York, Oregon, Florida, and Massachu- setts) have taken approximately 30 programs given by 24 trained facilitators. Extensive subjective evaluations were obtained from all participants after each session of each program. Participants were asked to indicate the extent to which they thought each of the 16 objectives were mastered, which aspects of the program they liked best and which they liked least, to what extent they thought the separate components of the training were useful (lecture, videotape, role-play, audiotape, etc), and whether they would recommend this program to colleagues.

Subjective evaluations have been remarkably positive. This finding was particularly gratifying in that the apparent skill level of the physicians taking the program has been very diverse. Many PCPs taking the program did not routinely diagnose and treat depression themselves, while many others indicated a high degree of confidence in the management of depression. Since all PCPs completing DEP indicated such a high degree of satisfaction, it seemed clear that the program materials were sufficiently robust to enable facilitators to pitch the program to the appropriate level _of the learners.

On a five-point scale, with "1" representing failure to reach the objective and "5" representing re- alization of the objective, the mean learners' ratings on the attainment of each of the 16 program objectives were, without exception, between 4.5 and 5.0. Similarly, on another five-point Likert scale con-

cerning the usefulness of each aspect of the program (e.g., lecture, video, role-play practice), all aspects of the program also received mean satisfaction ratings between 4.5 and 5.0.

Qualitative feedback was also very positive. Learners commented favorably on the informal, interactive quality of the program, and appreciated the focus on communication skills, in addition to psychopharmacology. No consistent comments were received regarding aspects of the program that participants would change. Very few comments in this domain were received (most said "no change recommended") and criticisms tended to be idiosyncratic and often conflicting with each other. For example, some participants indicated that the lecture was "too long," while others thought the lecture was "too short." Every participant taking this program, without exception, commented that this is a program they would recommend to colleagues.

A randomized, prospective educational efficacy trial was conducted among 49 PCPs in Portland, Oregon in 1997. The results of that study indicated that PCPs receiving the program were able to de- monstrably improve their performance on several measures of communication skills, as well as patient satisfaction, compared to untrained control physicians. Ratings of skills were performed by trained simulated patients (unknown to PCPs) with symptoms of major depression, who were blind to PCP training group. These changes occurred without any corresponding increase in the total interview time the trained PCPs spent with their patients. Thus, trained PCPs were able to improve their psychosocial interviewing skills, without increasing their total interview time with patients. Details of this study have been published elsewhere [121.

Future Direct ions

Current Plans for DEP

DEP currently is being evaluated in a second prospective randomized, controlled study of outcome among 120 PCPs in a regional, network-model health maintenance organization (HMO). While Gerrity's original study examined physicians' communication skills, this second study will examine physicians' antidepressant prescribing patterns, related utilization measures, and changes in PCPs' knowledge, attitude, and confidence.

Regarding dissemination, DEP is being modified

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for use in low-income and ethnically diverse pop- ulations, as well as for use by obstetricians-gyne- cologists. The American Academy of Family Physi- cians has endorsed the Program as part of its Year 2000 Mental Health Initiative. The Florida Acad- emy of Family Physicians has also sponsored state- wide dissemination of the Program, which was launched in November, 1999. The VISN-3 network of Veteran's Administration Hospitals in the North- east (Bronx, Manhattan, Brooklyn, Hudson Valley, Northport, and Newark) has recently completed a facilitator training program designed to deliver DEP to PCPs and specialists in its eight sites.

Disease Management of Depression

DEP by design is only an educational program. Health services research now clearly demonstrates that changing patient outcomes requires significantly more modification of medical care than just the implementation of educational programs. Whether the chronic medical condition is conges- tive heart failure, diabetes, or depression, current thinking now advocates for population-based, disease management interventions to truly improve the clinical outcome of large groups of patients [21].

The important elements in an effective depression disease management system require effective education, objective diagnostic tools, standardized outcomes measures, a system to monitor outcomes and feed the information back to PCPs, access to specialist care, patient self-care, a mechanism to insure accountability, and adequate incentives to motivate physician adherence to intended procedures [22].

The authors of this contribution and the MacArthur Foundation Initiative on Depression in Primary Care understand that DEP, standing alofie, has limited ability to make a long-standing inde- pendent contribution to improved clinical outcomes in the treatment of depression. DEP should be utilized as part of an overall health system's effort to improve outcome and be integrated into overall disease management strategies.Several current research efforts are now underway to assess the impact of DEP on patient outcome, standing alone or as part of a disease management program.

C o n c l u s i o n

This paper presents the need, rationale, design, and subjective evaluation of the MacArthur Foundation Depression Education Program for Primary Care

Physicians. Encompassing both the cognitive knowledge as well as the communication skills necessary for the effective assessment and management of depression in primary care, the authors believe the program has the potential to become an important vehicle, especially when integrated into more systematic disease management programs, to improve depression outcomes in the primary care sector. Further tests of efficacy, as well as multiple dissemination efforts are now underway.

R e f e r e n c e s

1. Murray C, Lopez A: the Global Burden of Disease. Boston, Harvard School of Public Health, World Health organization, 1996

2. Rush AJ, Golden WE, Hall GW, et al: Depression in Primary Care: Clinical Practice Guideline. Agency for Health Care Policy and Research. AHCPR Publica- tion No. 93-0550. Rockville, MD, US Department of Health and Human Services, 1993

3. Simon GE, Von Korff M: Recognition, management and outcomes of depression in primary care. Arch Faro Med 4:99-105, 1995

4. Lin E, Von Korff M, Katon W, et ah the role of the primary care physician behavior and patient's adherence to antidepressant therapy. Med Care 33:67-74, 1995

5. Schulberg H, Block MR, Madonia MJ, et al: Treating major depression in primary care practice: eight month clinical outcomes. Arch Gen Psychiatry 53: 913-919, 1996

6. Katon W, Von Korff M, Lin E, et ah Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 273:1026-1031, 1995

7. Greenberg PE, Stiglin: LR, Finklestein SN, et al: Depression: a neglected major illness. J Clin Psychi- atry 54:419-424, 1993

8. Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients: results of the Medical Outcomes Study. JAMA 262 914-919, 1989

9. Coyne J, Schwenk TL, Fechner-Bates S: Non-detection of depression by primary care physicians reconsid- ered. Gen Hosp Psychiatry 17:3-12, 1995

10: Simon GE: Can depression be managed appropriately in primary care? J Clin Psychiatry 59(suppl 2)3-8, 1998

11. Rost K, Zhang M, Fortney J, et al: Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry 20:12-20, 1998

12. Gerrity M, Cole S, Dietrich AJ, Barrett JE: Improving the recognition and management of depression: is there a role for physician education? Arch Family Practice 48:857-949, 1999

13. Bird J, Cohen-Cole SA, Boker J, Freeman A: Teaching psychiatry to non-psychiatrists physicians: I. The ap-

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plication of educational methodology. Gen Hosp Psy- chiatry 5:247-53, 1982

14. Badger LW, deGruy F, Hartman J, et al: Psychosocial interest, medical interview, and the recognition of depression. Arch Fam Med 3:899-907, 1994

15. Williams JW, Rost K, Dietrich AJ, et al: Primary care physicians approach to depressive disorders: effects of physician specialty and practice structure. Arch Fam Med 8:58-67, 1999

16. Stewart MA: Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 152:1423-33, 1995

17. Giron M, Manjon-Arxe P, Peurto-Barber J, et ah Clinical interview skills and identification of emotional disorders in primary care. Am J Psychiatry 155:530-535,1998

18. Roter DL, Hall JA, Kern DE, et ah Improving physicians' interviewing skills and reducing patients' emo-

tional distress: a randomized clinical trial, Arch Int Med 155:1877-1884, 1995

19. Levinson W, Roter D: The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Int Med 8:318-324, 1993

20. Smith RC, Lyles JS, Mettler J, et al: The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Int Med 128:118- 126, 1998

21. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH: Collaborative management of chronic illness. Ann Int Med 127:1097-1002, 1997

22. Katon W, Von Korff M, Lin E, et al: Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychi- atry 19:169-178, 1997

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Participant's Workbook

The MacArthur Foundation. Depression Education Program for

Primary Care Physicians ~

Steven Cole, M.D.,

Mary Raju, R.N., M.S.N., F.N.P.,

James Barrett, M.D.,

Martha Gerrity, M.D., Ph.D.,

Allen Dietrich, M.D.

1 This program has, in the past, been approved for Continuing Medical Education credits by Hillside Hospital (North Shore-Long Island Jewish Health System) and the Foundation for Medical Excellence, Northwest Center for Physician-Patient Communication.

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TABLE OF CONTENTS

Sect ion 1

Sect ion 2

Sect ion 3

Sect ion 4

Sect ion 5

Sect ion 6

Sect ion 7

Sect ion 8

Sect ion 9

Sect ion 10

Sect ion 11

Sect ion 12

Sect ion 13

Sect ion 14

Program Objectives

Agenda: Session I

Lecture Guide 1: Slide Presentation

Interview Checklist

SPAR

Case Study

Tool Kit

Audiotape Instructions

Monograph: Assessment and Management of Depression in Primary Care Practice

Agenda: Session II

Lecture Guide 2: Slide Presentation

Outcomes Management Cases

Table of Antidepressants

Consultants

(p. 310)

(p. 311)

(p. 312)

(p. 325)

(p. 326)

(p. 327)

(p. 328)

(p. 331)

(p. 334)

(p. 347)

(p. 348)

(p. 353)

(p. 354)

(p. 355)

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SECTION 1: P R O G R A M OBJECTIVES

A. Knowledge Objectives

After participating in both sessions of this workshop, the physician will be able to:

1. Diagnose major depression and differentiate it from both chronic depression [dysthymia] and minor depression [adjustment disorder and depressive disorder not otherwise specified] in adults.

2. Specify management strategies for each of these three types of depression in adults.

3. List the indications, side effects, and starting dosages for at least two antidepressant medications.

4. Describe a procedure for outcomes management of patients started on antidepressant medications.

5. Explain psychosocial approaches to the manage, merit of depression.

6. State the criteria for mental health referral.

B. Skills Objectives

After participating in this workshop, the physician will be able to use:

1. Open-ended questioning that permits patients to describe their chief complaints without interruption.

2. Facilitation techniques that encourage patients to elaborate on presenting complaints without premature closure.

3. Techniques of surveying to allow patients to describe all of their concerns.

4. Specific questions to evaluate mood, the presence of anhedonia, and current life stresses.

5. Focused questions to evaluate the impact of the patient's symptoms on quality of life.

6. Direct questions to elicit patients' expectations of medical care.

7. Rapport-development skills such as reflection and legitimation to respond to patients" emotions.

8. Clear and concise questions to evaluate suicidal ideation.

9. Basic concepts of education and learning to explain the diagnosis and management of depression.

10. Negotiation skills for patients who do not accept the diagnosis of depression.

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SECTION 2: A G E N D A

Session I

7:30 AM Registration 10:00 • Breakfas t • I n fo rma l in t roduc t ions

8:00

8:30

9:45

Overview • O p e n i n g r e m a rks • Par t ic ipant in t roduc t ions • Discuss ion of pe r sona l l earn ing

objectives

Lecture • In teract ive d i scuss ion • Q u e s t i o n / a n s w e r pe r iod

Break

11:30

12:00 PM

Skills Workshop • In t e rv i ew checklist • Video of s imu la t ed pa t ien t • Skills pract ice

Conclusion • S u m m a r y • Ins t ruc t ions for ob ta in ing

aud io t apes • Use of tool kit

Adjournment • Eva lua t ions • L u n c h

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S E C T I O N 3: L E C T U R E G U I D E : S L I D E P R E S E N T A T I O N

Notes

The MacArthur Foundation Depression

Education Program

copyright by The MacArthur Foundation

A G E N D A PROGRAM I

• Lecture/discussion • Skills workshop

INTERSESSION • Patient audiotaping

PROGRAM II • Review of objectives

Audiotape review Skills practice Psychopharmacology practicum

flT~h

t,GLI,; , L E C T U R E O U T L I N E

• Ove rv i ew

• Types of depress ion

• B a r r i e r s to diagnosis

• Assessment

• Ef fec t ive c o m m u n i c a t i o n

• M a n a g e m e n t

~lTtYll

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D E P R E S S I O N IS C O M M O N

• 10% of men (lifetime) • 20% of w om en (lifetime) • Most c o m m o n menta l d isorder

in p r i m a r y care Depressed patients visit p r imary care physicians 3 times more often than patients not depressed

flTITIi

Notes

D E P R E S S I O N IS S I G N I F I C A N T

• Associated with suicidality • 50% recurs af ter t r ea tmen t ends • Increased morb id i ty /mor ta l i ty

f rom medical condit ions • C o m p o u n d s disabili ty and

impa i red funct ion • Costs $44 billion year ly

t,P,l l,; U N D E R - R E C O G N I T I O N /

~. U N D E R T R E A T M E N T

• 30%-70% of depress ion is missed

• 50% of pat ients stop medica t ion wi thin first 3 mon ths

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TYPES OF DEPRESSION

• Major depression • Chronic depression (dysthymia) .• Minor depression

--) adjustment disorder

--) depressive disorder nos

Notes

Ltktkl.; MAJOR DEPRESSION

Four Hallmarks:

• Depressed mood

• Anhedonia

• Physical symptoms

• Psychological symptoms

flTITh

DEPRESSED M O O D Hallmark 1

• Neither necessary, nor sufficient

• Can be misleading

• Beware of asking the question, "Are you depressed?"

' f'~lTh

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•I A N H E D O N I A

]ll Hallmark 2

[=~ • Loss of interest or pleasure • May be most important and

~l useful hallmark [[[[ • Ask, "What do you enjoy

Notes

P H Y S I C A L S Y M P T O M S Hallmark 3

• Sleep disturbance

• Appetite or weight change

• Low energy or fatigue

• Psychomotor changes

PSYCHOLOGICAL SYMPTOMS Hallmark 4

¢ Low self-esteem or guilt

¢ Poor concentration

. Suicidal ideation or persistent thoughts of death

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t,lkl,klJ DSM-IV C R I T E R I A F O R

M A J O R DEPRESSION

• Depressed mood or anhedonia • A total of 5 out of 9 symptoms • Symptoms that persist most of

the day, nearly every day, for 2 weeks

Notes

¢lYIYli

CHRONI C D E P R E S S I O N ( D YS TH YM IA )

• Characterized by 2 years of depressed mood, occurring more days than not

• Persists with at least 2 other symptoms of depression

• Increases risk of major depressive episodes

¢IYIYli

M I N O R D E P R E S S I O N

• )~djustment disorder

• Depressive disorder nos

• Significant disability

¢tYtYIi

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Notes ~l~,l,J

BARRIERS TO RECOGNITION

• Somatization

• Comorbidi ty

~ , • Stigma

• Fallacy of 'good reasons '

• 'Pandora ' s box'

• Discomfort with emotional issues

tlllJ,,I.,l

EFFECTIVE COMMUNICATION: THREE INTER VIEW FUNCTIONS

• Collect information

• R e s p o n d to emot ions

• Educate to mot ivate patients and famil ies

flTITlfl

~WJ, I J

BATHE

B ~Background: "What is going on ..."

A Affect: "How do you feel about..."

T Trouble: "What's troubling you ..."

H Handl ing: "How are you handling.. "

E Empathy: "That must be diff icult. . . "

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REFERRAL

Consider, if needed, for: • suicidality • bipolar disorder • psychosis • comorbid psychiatric conditions • lack of response to treatment • need for psychotherapy

[ITtTIi

Notes

PAUSE F O R D I S C U S S I O N

flTITIi

T R E A T M E N T

• Pharmacotherapy

• Psychotherapy

• Psychosocial interventions

rlTITIi

s18


P H A R M A C O T H E R A P Y

• Effective for ma jo r depression • Effective in chronic

depression (dysthymia) " • Untested in minor depression

ftTtTh

Notes

L,l l lJ

T R E A T M E N T G U I D E L I N E S

• Titrate agent to achieve therapeutic dose or remission

• Full effect may take 4-6 weeks • Treat for 4 to 9 months after

full remission • Use prophylactic medication for

recurrent depressions

flTlYh

P R O M O T I N G A D H E R E N C E

• Inquire into pr ior use of and experience with antidepressants

• Advise to take medication daily • Explain that it may take 2 to 4

weeks for therapeutic effects • Encourage patients to engage in

pleasant activities

ftY4Th

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S. Co le e t al.

/1[I " Advise patients to take kUI medication if they feel better

• Tell patients to call physician before stopping medication

Itll • Instruct patients on how to

Notes

ANTIDEPRESSANTS • TRICYCLICS • SSRIs

-~ c i t a lop ram (Celexa) -} f luoxet ine (Prozac) ~ paroxe t ine (Paxil) _~

_~ ~ ser t ra l ine (Zoloft) • OTHER NEW AGENTS

-~ bup rop ion (Wel lbu t r in ) - DA/NE --> mi r t azap ine (Remeron) - NE/SHT

nefazodone (Serzone) - SRI /5HT -~ reboxe t ine (Vest ra) - NRI --) venlafaxine (Effexor) SRI /NRI

(ITITII

T R I C Y C L I C ANTIDEPRESSANTS

Side Effects: • anticholinergic • antihistaminergic • antiadrenergic • quinidine-like effects * nortriptyline and desipramine

least toxic

I1TITh

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t.iAIJ, IJ ADVANTAGES OF SSRIs

AND O T H E R N E W AGENTS

• Fewer side effects • Safety • Increased patient satisfaction

• Improved adherence to therapy

• Cost savings

¢IYIYI~

Notes

LIJ, lJ, l,; C H O O S I N G A M O N G SSRIs AND O T H E R N E W AGENTS

Evaluate: • half-life • drug interactions • side effects

¢IYIYh

,tW~b

HALF-LIFE

Long (longer than 1 day) -~ fluoxetine (Prozac) Short --) other SSRIs (once a day) --) (Effexor XR) (once a day) --) (Wellbutrin SR)(1-2x/day) --) other new agents (2x/day)

::(IYIYh

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D R U G I N T E R A C T I O N S

• Obtain medication history • Be aware that all drugs can

affect the action and serum levels of other drugs

• Monitor the clinical effects and serum levels of all medications

Notes

tl,,tl,,tl, ,:

S I D E E F F E C T S (SSms)

i Agitation/Insomnia

i GI distress

• Sexual dysfunction

f'lYl'rl'

t~!~l,,J,,[J , ':

SIDE EFFECTS (OTHER NEW AGENTS)

• b u p r o p i o n - agitation

. mir tazap ine - Sedation, we ight gain

• n e f a z o d o n e - sedat ion

• reboxet ine - in somnia

• venlafaxine - GI distress, elevated Be

ll.rl,riYh ii.

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P S Y C H O T H E R A P Y

Effective for mild to moderate major depression

• Useful adjunct to medication • Possibly effective in chronic and

minor depression • Helpful for patients in life

transitions or personal conflicts

Notes

PSYCHOSOCIAL INTERVENTIONS

(BY PRIMARY CARE PHYSICIAN)

t Watchful waiting

• Office counseling

• Physician support

(ITITh

" S P E A K "

S schedule regular activities P plan pleasant events E exercise A assertiveness K kind thoughts about self

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L,&t,L, LJ : FOLLOW UP

• Assess every 2 to 4 weeks • Use DSM-IV checklist and

severity tool • Ti t ra te dose for total remission • Main ta in effective dose for 4 to

9 mon ths • Cons ider ma in tenance the rapy

ftTITh

N o t e s

l,l,ll~l,J P A R T I A L O R N O

R E S P O N S E

• Check for adherence • Re-evaluate diagnosis • Adjus t dosage • Change medica t ion • A dd psycho the rapy • Call for psychiatr ic consultat ion

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SECTION 4: INTERVIEW CHECKLIST (Were the following skills appropriately implemented?)

L Function One: General Skills A. Attentive listening

B. Open-ended questioning "Why are you here today?" "What do you know about depression?"

C. Facilitation "Tell me more about . . . Uh-huh, okay. . . ?

D. Surveying "Is there anything else you'd like to talk about?"

E. Summarizing "Let me see if I can summarize what you've told me."

F. Elicitation of patient's expectations "What would you like to see happen as a result of this visit?"

G. Inquiry about impact of symptoms on quality of life "Have these symptoms affected your daily living?"

Function One: Evaluation of Depressive Symptoms A. Depressed mood

B. Anhedonia

C. Physical symptoms: 1. Sleep 2. Appetite 3. Energy 4. Psychomotor agitation/retardation

D. Psychological symptoms: 1. Poor concentration 2. Low self-esteem or guilt 3. Suicidal ideation/thoughts of death

II, Function Two: Respond to Emotions A. Reflection

"So, I can see you're feeling down in the dumps."

B. Legitimation (validate emotions) "Coping with diabetes isn't easy."

IlL Function Three: Education About Depression A. Depression indicates a chemical imbalance

B. Depression is common

C. Depression is treatable

Function Three: Improving Adherence A. Medication takes time to work

B. Take medication daily or as ordered

C. Don't stop medication before contacting physician

D. Take medication even if you feel well

E. Engage in pleasant activities

F. Call physician if you have questions

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Absent

Absent

Absent Absent Absent Absent

Absent Absent Absent

Mild Moderate Severe

Mild Moderate Severe

Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe

Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

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S E C T I O N 5: S P A R

Guidelines for Practice of Interviewing Skills

Script the patient and select skills to practice.

P Practice skills.

A Assess interaction; obtain feedback from the "patient."

R Repeat exercise, focusing on skills to be improved.

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SECTION 6: C A S E S T U D Y

"Physician" Instructions

(William Adams). Your next patient is here for his first follow-up appointment after an emergency room visit two weeks ago. The ER sheet states, "chest pain with normal EKG; suspect acute stress reaction." Stress test one week later was negative. Your notes indicate that Mr. Adams works as an executive in a large computer firm.

After a brief screen to assess chest symptoms, you evaluate Mr. Adams to determine whether he has a depressive disorder. If he meets the criteria for depression, you will educate the patient about his illness and develop a mutually agreeable treatment strategy.

"Patient" Instructions

(William Adams). You are a 51-year-old, recently divorced executive coming in for follow up

after an emergency room visit for chest pain two weeks ago. Cardiac testing showed no abnormali- ties at that time, and a stress test one week later was within normal limits.

You think you must have a medical condition because you continue to have the sensation of pressure in your chest, especially when you are under stress. You are tired all of the time and have trouble sleeping at night. Although it is becoming difficult to concentrate and perform well at work, you cannot tell anyone. Any illness could be used as an excuse to outsource you.

Your family complains that this lack of energy has caused you to gain weight, but you don't have motivation to exercise. Since the divorce, life seems to offer little more than an empty apartment. All you do is work 13 hours a day to keep up at your job.

You would like the doctor to prescribe something to help you sleep.

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Name

S E C T I O N 7: T O O L K I T

Depression Screening and Diagnostic Evaluation 2

Today's Date

INSTRUCTIONS: This questionnaire will help your doctor better unders tand problems that you may have. Please put an X in the box beneath the answer that best describes how you have been feeling.

During the past month, have you often been bothered by:

1) little interest or pleasure in doing things

2) feeling down, depressed, or hopeless

Yes No [] []

[] []

> If you checked "No" to both questions, you do not need to complete the rest of the questionnaire.

> If you checked "Yes" to either question, please answer each of the nine questions presented below.

3) How often have you been bothered by each of the following symptoms during the past 2 weeks? For each symptom put an "X" in the box beneath the answer that best describes how you have been feeling.

Several More than Nearly Not at all days half the days every day

(0) (1) (2) (3)

a) Feeling down, depresseG or hopeless [ ] b) Little interest or pleasure in doing things [ ] c) Trouble falling or staying asleep, or sleeping

too much [ ] d) Feeling tired or having little energy [ ] e) Poor appetite or overeating [ ] f) Feeling bad about yoursel f - -or that you are a

failure or have let yourself or your family down [ ]

g) Trouble concentrating on things, such as reading the newspaper or watching television [ ]

h) Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual [ ]

i) Thoughts that you would be better off dead or of hurt ing yourself in some way [ ]

[] [] [] [] [] []

[] [] [] [] [] [] [] [] []

[] [] []

[] [] []

[] [] []

[] [] []

2 Major depression if response to ~5 symptoms (a-i) is "nearly every day" (count i if present at all) and a~ least 1 of those symptoms is a or b. Other depression syndrome if response to 3 symptoms is at least "more than half the days" (count i if present at all) and at least i of these symptoms is a or b. This instrument was modified by David Brody, M.D., from PRIME-M.D. Patient Health Questionnaire (PHQ), copyright held by Pfizer, Inc., but it may be photocopied ad libitum.

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DSM IV INTERVIEW CHECKLIST

I. DEPRESSED MOOD

II. ANHEDONIA

III. PHYSICAL SYMPTOMS A. Sleep disorder

B. Appetite or weight change

C. Low energy

D. Psychomotor changes

IV. PSYCHOLOGICAL SYMPTOMS A. Poor concentration

B. Low self-esteem or guilt

C. Suicidal ideation

0 1 2 3 Absent Mild Moderate Severe









DSM 1V Score

Patient Name Date

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Patient Name:

DEPRESSION OUTCOMES MO NI T OR

Flowsheet

0 1 2 3 Symptom Ratings: Absent Mild Moderate Severe

Date Date Date Date Date

Medication(s )/Dose(s):

I. Depressed mood

II. Anhedonia

III. Physical Symptoms A. Sleep disorder

B. Appetite or weight change

C. Low energy

D. Psychomotor change

IV. Psychological Symptoms A. Poor concentration

B. Low self-esteem or guilt

C. Suicidal ideation

DSM IV Score --~ (Sum 6f the 9 symptoms above)

Comments:

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SECTION 8: AUDIOTAPE INSTRUCTIONS

AUDIOTAPE OF PHYSICIAN/ PATIENT ENCOUNTER

Purpose

Recording interviews with patients allows you to focus on the process of the physician/patient interaction. Small changes in an interviewing approach can impact both the efficiency of an interview and accurate assessment of emotional distress, eventu- ally leading to improved patient outcome.

Procedure

One teaching method used in The MacArthur De- pression Education Program is the recording of a patient interview. Physicians then select one five- minute segment of this interaction to review with colleagues. Ideally, this segment will reflect some problematic aspect of physician/patient communication relative to each participant.

Guidelines

• Select a segment from one patient interview;

• Choose a patient with some form of depression or emotional distress;

• Ask this patient to schedule an appointment with you;

• Explain the audiotaping process

• Advise the patient that this recording is to be used solely for learning purposes.

Alternative Method

Designate one-half day session to tape record all of your patients. Select one segment of one patient interview to review with program participants.

Conclusion

Please make it clear to patients that recordings will be confidential and shared only with colleagues for training.

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A U D I O T A P E REVIEW PLEASE C O M P L E T E A N D B R I N G T O S E S S I O N T W O

1. Describe the interview situation.

. Please describe communicat ion skills you used well (efficiently/effectively) in the selected five-minute segment.

A.

B.

C.

3. From the same five-minute segment, please describe at least one issue or problem that y o u wou ld like to be able to manage more effectively.

4. Please t ry to identify a different approach to the problem or issue stated above that might p rove more efficient or more effective.

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PATIENT C O N S E N T FOR A U D I O T A P E

I hereby give my consent to Dr. to audiotape our conversation on this date, . I understand that the recording is to be used only as an educational tool to help physicians interview and communicate with patients. I understand that my name will be kept confidential.

Patient Signature Date

Witness

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SECTION 9: PARTICIPANT'S M O N O G R A P H : A S S E S S M E N T A N D M A N A G E M E N T OF DEPRESSION

IN PRIMARY CARE PRACTICE

Steven Cole, M.D.

Mary Raju, R.N., M.S.N., F.N.P.

James Barrett, M.D.

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O V E R V I E W

Major depression is a potentially chronic and recurrent illness with lifetime prevalence approximating 10% in men and 20% in women [1]. Dysthymic disorder (chronic depression) and other subthresh- old depressive disorders (minor depression) further increase these figures. Depressive disorders are associated with excessive utilization of medical services, marked morbidity, staggering economic costs, and significant mortality from suicide as well as from comorbid medical illnesses [2-5]. Despite a tendency to explain away the presence of depressive symptoms as an expected consequence of life stresses or physical illnesses, major depression should be viewed as a serious complication of such circumstances warranting aggressive intervention.

This monograph discusses the prevalence of depression in primary care, along with its associated problems of under-recognition, undertreatment, morbidity, mortality, and marked economic costs. Assessment, communication, and management strategies for major, chronic, and minor depression are discussed. Recommendations are based on scientific evidence and are consistent with the clinical practice guidelines for depression developed by the Agency for Health Care Policy and Research [1].

Depression is Common in Primary Care

More individuals suffering from mental disorders receive their care from primary care physicians than from psychiatrists or other mental health pro- fessionals [6]. Depression is probably the most common mental disorder in primary care practice, with increases from 2-4% in the community setting, to 5-10% in outpatient care, and 6-14% in medical inpatient units [7]. Because depressed patients in primary care settings Commonly present with somatic symptoms rather than complaints of depressed mQod, clinicians must be proficient in the assessment and management of depression. T h e skillful differential diagnosis of depressive symptoms is essential because major depression commonly presents as an associated problem in patients with other physical illnesses [8]. In addition, it has been found that 10-15% of all depressions may be caused by a physical illness or medication [1].

Depression is Often Unrecognized and Undertreated

Numerous studies indicate that 30-70% of cases of major depression are undiagnosed or undertreated

in primary care [9]. While some observers note that physicians are more likely to identify severe depression and to miss only milder forms of the illness [10], Rost and colleagues recently demonstrated that nearly half of the undetected patients with depression in primary care developed suicidal ideation and 53% continued to meet criteria for major depression one year after the index evaluation [11].

Even when diagnosed, depression may go untreated or partially treated. Katon and colleagues report that 55% of diagnosed patients in primary care receive no treatment and 34% receive inadequate treatment [7]. Two recent randomized intervention trials found that more than 50% of patients in the "treatment-as-usual" group remained depressed I year later, in contrast to a 70% or greater recovery rate in the intervention group [12,13].

Physician, patient, and system variables probably account for these disturbing findings. Several theo- ries have been offered, including health services issues, sociocultural barriers, poor consumer education, and insufficient physician knowledge level [14,15]. Patient denial, cognitive impairment, lack- ing awareness of depressive symptoms, and inability to articulate symptoms compound the difficulties of detecting depression in primary care. Patient nonadherence, resistance to diagnosis, cultural factors, social forces, subtherapeutic dosages of antidepressants, and low insurance reimbursement rates lead to the inadequate treatment of depression. Many employment, health, disability, and life insurance practices discriminate against individuals with mental illness, thereby reinforcing stigma and adversely affecting their socioeconomic status.

Depression Causes Significant Morbidity and Mortality

Suicide is a common consequence of unrecognized or undertreated depression. Regier reports that depressive disorders account for 16,000 deaths annually. Approximately 15% of patients with severe depression lasting at least I month succeed in kill- ing themselves [16]. Studies indicate that one-third to one-half of those who have committed suicide had seen their physicians within the month preced- ing their deaths [17]. More recent reports demonstrate that 75% of elderly patients who committed suicide had seen a primary care physician shortly before their deaths [18].

Major depression is a risk factor for death in patients with medical illnesses. Following myocar-

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S. Cole et al.

dial infarction, patients with major depression are three times more likely than nondepressed patients to die within the subsequent year [19]. Depressed patients admitted to nursing homes are 56% more likely to die within the subsequent year compared to nondepressed patients in nursing homes, con- trolling for severity of physical illnesses [20]. The Medical Outcomes Study demonstrated that patients with depressive symptoms, with or without a major depressive disorder, had worse physical functioning, less social interaction, and spent more days in bed than patients with medical conditions such as arthritis, hypertension, angina pectoris, and diabetes [21].

The Economics of Depression

Depressive disorders are a national economic concern costing approximately $43.1 billion annually, based on figures from 1990. With $7.7 billion attrib- uted to direct treatment costs [5], the remaining expenses reflect reduced productivity, absenteeism, and mortality. Depressed patients also contribute to escalating medical costs through extensive utilization of services, including outpatient visits, labora- tory procedures, and hospitalizations [2]. In exam- ining records of the top 10% of utilizers of outpatient services, Katon et al. found evidence of recurrent depression in approximately one-third of the patients, and noted that more than two-thirds of depressed patients make at least six visits a year to primary care physicians for somatic complaints [22].

Signs and Symptoms of Depression

Patients and physicians often think of depression as a symptom of personal weakness, social maladjust- ment, or even divine retribution. Depression, however, represents a clinical syndrome with biological changes characterized by a specific cluster of signs and symptoms. It presents in three distinct forms to the primary care physician: major depression, chronic depression, and minor depression. Accord- ing to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), chronic depression is also known as "dysthymia" and minor depression is classified as "adjustment disorder with depressed mood" or "depressive disorder not otherwise specified [nos]" [23].

Major Depression

DSM-IV identifies nine signs and symptoms of major depression that can be categorized into four groups:

• Depressed mood: subjective feelings of sadness or emptiness most of the day, nearly every day;

• Anhedonia: markedly diminished interest or pleasure in all or almost all activities;

• Physical Symptoms: fatigue, significant change in appetite or weight, sleep disturbances, and psychomotor retardation or agitation;

• Psychological Symptoms: feelings of worthless- ness, inappropriate guilt, inability to concentrate, and recurrent thoughts of death or suicidal ideation.

For a diagnosis of major depression, the patient must have exhibited either a depressed mood or a markedly diminished interest in enjoyment or pleasurable activities, and four other symptoms; three, if both depressed mood and diminished pleasure are present. These symptoms must be present for at least 2 weeks, occurring most of the day, nearly every day.

Chronic Depression

Chronic depression or dysthymia is characterized by persistent depressed mood, present for more days than not, for at least a 2-year period of time. Depressed mood must be accompanied by two other depressive symptoms (see above list for major depression). These symptoms must be present for at least 2 years, with no major depressive episode.

Dysthymic disorder does not represent a major depressive episode in partial remission. Many patients have suffered with dysthymia for their entire adult lives, and some may have come to accept depressed mood as a part of life [24]. A large majority of individuals with dysthymia, however, will develop major depressive episodes.

Minor Depression

Sadness is an appropriate response to stressful life events, such as job loss, death of a family member, loss of a Close friend, health impairment, marital difficulties, or financial hardship. When the reaction appears excessive or continues for longer than 2 months, these patients are considered to have an

ad jus tment reaction with depressed mood. Other patients may have mixed depressed mood and anxiety symptoms, some of which recur on an inter- mittent basis.

Patients suffering from one of these depressive disorders that do not fit well into any other cate- gory can be diagnosed with the syndrome of minor

336


depression or, according to DSM-IV, depressive disorder (nos).

These minor forms of depression are distin- guished from major depression by the absence of a full complement of five depressive symptoms, and from chronic depression by their shorter duration. If at any time, however, the symptomatology changes, the diagnosis and management strategies should be adjusted accordingly.

EFFECTIVE C O M M U N I C A T I O N SKILLS

Research in primary care settings during the last decade demonstrates that the use of specific communication techniques is associated with important positive healthcare outcomes. These include patient and physician satisfaction, adherence to treatment, fewer malpractice claims, and biologic outcomes in some diseases [25-28]. Effective communication skills are particularly critical for the successful diagnosis, treatment, and referral of patients with depression [29-30]. These skills can be learned [31].

I. Gathering Data

Open-Ended Questions. Physicians should allow patients to describe their chief complaints without interruption by using open-ended questions that cannot be answered with a simple "yes" or "no" response. Introductory open-ended questions (e.g., "How can I help you today?") allow patients to explain their problems in their own words. Stud- ies show, however, that physicians tend to interrupt patients, on average, within the first 18 seconds of an interview [32]. These interruptions lead to premature closure, diagnostic errors, and inefficiency.

Surveying. Sometimes initial complaints divert attention frbm more significant underlying concerns. Patients raising issues associated with em- barrassment, shame, or fear often require a high level of comfort with the physician. Therefore, after presenting complaints have been addressed, the physician should promote further discussion regarding other problems the patient-may not have mentioned. For example, "Before we go talk more about your headaches, I'd like to hear about anything else that may be bothering you." This open- ended statement is more productive than asking, "Are there any other problems?" This closed-ended ("yes/no") inquiry can easily lead to patient denial.

Many patients view physicians as providers of tra- ditional medical services, and may need some prompting to discuss depressed mood or related issues.

Physicians may be apprehensive that surveying might encourage the patient to unload a plethora of complaints or open a "Pandora's box" of emotional issues that can take up more time than the physician has available. On the contrary, however, surveying can help to avoid troublesome "doorknob" questions. "Oh, by the way, doctor . . . . " at the end of a visit can be time-consuming and distressing. These interactions occur in 20% of all physician- patient encounters [33]. Surveying and clarifying issues in early stages of the interview actually saves time and decreases frustration. Furthermore, these techniques may be instrumental in drawing attention to the patient's most distressing problems.

Facilitation Techniques. Patients describing their concerns may need prompting to speak in an open-ended manner. The physician can sometimes facilitate an interaction by using nonverbal cues, such as head nodding, silence, or verbal phrases. "Can you tell me more about it?" or "Go on, please." Sometimes it is helpful to repeat the last phrase of a patient's sentence or nod, while saying "uh-huh." Silence may facilitate further discussion.

A truly loquacious patient may need help staying focused by a gentle interruption: "I'm glad your Aunt Thelma is doing so much better, but right now I'm concerned about your headaches, and I'd like to hear more about them."

Assessing Mood, Anhedonia, and Other De- pressive Symptoms. Physicians should inquire directly about mood by using open-ended questions and facilitation techniques. "How's your mood been lately?" may be more productive than the closed question, "Have you been depressed?" The latter requires patients to understand depression and to then make their own diagnosis. Further- more, fear of social stigma may invite denial, defensiveness, or irritation in response to direct questions about depression. Patients often prefer terminology such as feeling "down, .... irritable," or "not myself lately" since "being depressed" is commonly viewed as a sign of personal weakness.

Patients who deny a depressed mood should be screened for anhedonia. This is particularly important in anxious patients not aware of an underlying depressed mood, in patients with chronic general medical illness, and in those recently subjected to

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S. Cole et al.

acute stresses. Screening questions for anhedonia include, "What are you doing for fun?" or "Does your . . . (pain/anxiety/grief) keep you from . . . (golfing, bowling, gardening, seeing the grandchil- dren, attending religious services)?" [34,35].

An indication of either depressed mood or anhedonia signals the need to screen for other symptoms of major depression. The physician might ask, "How's your energy level been lately?" Other significant symptoms are evaluated by asking, "How have you been sleeping?" and "How's your appetite been?" Direct questions can be used to assess loss of self-esteem ("Have you been down on yourself or feeling guilty?"), lack of concentration ("How's your concentration been lately?"), and suicidal thoughts ("Have you thought of hurting yourself?") [34].

Determination of Function. Patients should be asked in what ways their symptoms have caused physical, social, or role impairment. For example, "How has your pain affected your ability to work?" or "How has the pain affected your sexual life?" Querying patients about function encourages discussion of underlying emotional distress and facilitates making the diagnosis of a mental disorder. Once depressive symptoms have been revealed, questions about function also help the physician to evaluate the severity of a depressive syndrome.

Ascertaining Patient Expectations. Asking patients about their expectations of care reveals underlying reasons for their seeking care, helps detect emotional aspects of their complaints, and promotes therapeutic partnerships, Understanding patient expectations enables physicians to better sat- isfy patients, facilitates patient acceptance of diagnoses, and promotes ~nutual agreement on treatment plans.

II. Responding to Patients' Emotions

Reflection and Legitimation. By accepting intense feelings of sadness, anger, and anxiety in a non-threatening manner, physicians build rapport and establish a trusting relationship with depressed patients. Failure to address emotions reflects lack of physician concern, leading patients to feel distant and defensive. Two techniques that are particularly useful in responding to patients' emotions are reflection and legitimation [35]. Reflection acknowl- edges the patient's feeling by naming it in a nonac- cusatory, nonjudgmental way. For example, "It

seems that talking about this pain upsets you . . . . " or "Sounds like a frustrating situation for you." These statements convey physician empathy, build rapport, and elicit information about crucial issues.

When using reflection, choose familiar phrases, use non-threatening words, and avoid overstating the sentiment. Patients can more easily hear that they seem "frustrated" or are "feeling down" than being "angry" or "in despair." If emotions are un- derstated, the patient can amplify: "I 'm not just frustrated, I 'm angry." Inappropriately labeling a reaction as something more intense than the patient is ready to acknowledge can create barriers to communication by evoking feelings of shame, guilt, or defensiveness.

A patient's unwillingness to pursue a subject should be acknowledged and respected. When emotional issues are clearly too complex to be addressed during one encounter, the physician can acknowledge their importance in a supportive manner and arrange for another visit to further explore the problem. Alternatively, a referral can be made to a mental health specialist.

Legitimation refers to statements that signal physician acceptance of the patient's feelings. "I can understand that your pain is tiring and upsetting to you." Or, "It makes sense that you'd be anxious after losing a good job." Another form of legitimation puts the patient's experience within the context of a universal response. "Many people would feel that w a y . . . I've had many patients go through what you've described."

Focused Questioning to Assess Suicidal Ide- ation. Studies indicate that approximately 80% of seriously depressed patients think about suicide. Depressed patients should be directly questioned about thoughts of hurting themselves. Begin questioning in a sensitive manner, with a gradual pro- gression toward more focused inquiry. Ask several questions to determine the presence of hopelessness. "How does the future look to you?" or "Do you think things will get better?" Although seriously depressed patients often express a deep sense of hopelessness, not everyone with a feeling of despair contemplates suicide. Identifying the suicidal patient requires focused questioning. "Lixdng with (pain/anxiety/illness) can be very difficult. Do you sometimes wish your life was over?"

Despite the fear of some clinicians, there is no evidence to suggest that talking about suicide will introduce a new idea or provoke the patient to take action. On the contrary, discussing the subject may

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relieve some of the anxiety patients may have about suicidal thoughts and could discourage them from taking action [36]. Patients with an equivocal response to questions about suicidal ideation should be probed for evidence of specific plans. "Tell me if you've thought about how you might hurt yourself?"

Patients with specific plans are at greater risk for suicide than those who only think about it or express concerns. In addition, other risk factors for suicide include hopelessness, social isolation, a personal or family history of previous suicide at- tempts, substance abuse, chronic physical illnesses, psychosis, male gender and advanced age.

Patients judged to be at risk for suicide should be referred immediately to a psychiatrist. When this is impossible, the physician may ask patients to enter into a "no-suicide contract" whereby they agree to contact the physician if they feel unable to control suicidal impulses. Patients who refuse to enter the agreement or whose agreement is unconvincing are candidates for immediate hospitalization or invol- untary commitment.

"BATHE". Developed by Marian Stuart [37], BATHE is a mnemonic for a five-step, ultra-brief, highly structured interviewing intervention for gathering data relevant to behavioral disorders and providing emotional support. Many primary care physicians have found this approach useful, given the time constraints of a busy practice.

• "B" stands f o r "background." The question, "What is going on in you life?" ascertains the psychosocial context of the patient's visit.

• "A" stands for "affect" and can be addressed by asking, "How do you feel about (what has been going on in your l i fe) . . . "

• "T" stands for "trouble," which can be assessed by asking, "what troubles you most about this?" This question usually leads to the most revealing and p~0ductive responses.

• "H" refers to "handling." The question, "How are you handling that?" focuses on the patient's coping abilities.

• "E" stands for "empathy" and indicates that all probing psychosocial inquiries should include an explicit statement of empathic physician support.

Stuart suggests that the BATHE approach can also provide the structure for follow-up visits around psychosocial problems. For these visits, she recom- mends the first question be changed to, "Tell me

what has been happening since I saw you last." The rest of BATHE then remains the same.

III. Developing a Management Strategy: Educational Techniques

Before presenting a diagnosis, the physician should determine the patient's understanding of depression in order to allay fears and educate the patient relative to his/her perceptions.

Assume that the patient already has a diagnosis and possible treatment options in mind, which may or may not correspond to your ideas. Useful questions to elicit these might be, "What has concerned you about with these s y m p t o m s . . , what have others told you?" Or, "I've described what I think the problem is; how does that fit with what you've been thinking?" Addressing patients' ideas and concerns directly can increase the efficiency of the interview and acceptance of the diagnosis [38].

Providing the Diagnosis. Statements used in presenting the diagnosis should be simple and suc- cinct. Patients are anxious at the time of diagnosis and should only be given small, discrete blocks of information. Once they have accepted the diagnosis, it is appropriate to explain the disorder in greater detail.

Some patients may have difficulty accepting the diagnosis of depression. "Doctor, I just know this isn't all in my mind!" Patients should be told that the disorder results from chemical changes in the brain and body that affect mood, thinking, sleep, and physical comfort, The changes can also be caused by another disease, by long- or short-term stress, or without clear cause.

The most important principle is to treat the depressive disorder when it is identified. The symptoms of depressive disorders are as debilitating as those associated with other common medical problems. Effective treatment is available, and patients deserve to feel better.

Responding to Patient's Emotions. After providing the diagnosis, pause to allow the patient to react and ask questions. The stigma associated with mental disorders may cause patients to become angry, frustrated, tearful, or cause them to reject the diagnosis of depression. Those w h o d o not verbal- ize their emotions may exhibit facial expressions, body gestures, and other nonverbal cues indicative of their distress: Verbal and nonverbal reactions

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should be acknowledged (reflection) and validated (legitimation).

Patient Education: Developing a Treatment Plan. The physician should stress that depression is a highly treatable medical illness caused by a chemical imbalance. The patient should understand that it is not a sign of personal weakness, and the vast majority of cases can be corrected with appropriate treatment. Recommendations for treatment should be offered, with the caveat that pharmacotherapy may take several weeks to take effect. Pa- tients often need to follow a regimen for several months to insure a full, sustained recovery.

Up to 50% of depressed patients in primary care will stop treatment within 3 months [39]. The following interventions are associated with increased patient adherence.

1. Ask about prior use of antidepressants. 2. Instruct patients to take medication daily. 3. Explain that it may take 2 to 4 weeks to notice the

benefit of treatment. 4. Advise patients to engage in pleasant activities. 5. Remind them to continue taking medication

even if they are feeling better, 6. Ask patients to call if they plan to stop taking the

medication. 7. Inform patients what to do if they have ques-

tions.

After allowing the patient to respond and ask questions, the physician should review a mutually agreed upon treatment plan to assess the patient's understanding and to increase adherence. A plan may be necessary to overcome barriers to compli- ance. Patients should be offered the opportunity to bring a family member or significant other to _the next visit to discuss the diagnosis and treatment plan. This is likely to provide emotional support for the patiertt and increase adherence to the medical regimen.

Consultation or Referral. The expertise of the primary care physician may determine whether patients with depression require consultation or referral. However, patients who are severely disabled, psychotic, suicidal, or refractory to treatment may require consultation or collaborative care provided by expert clinicians. Patients with psychosocial issues too complex to manage in a primary care setting may benefit from psychotherapy by mental health specialists. Successful referral, however, often involves overcoming significant barriers such as

patient reluctance (stigma) and managed care financial obstacles. Consultation is also indicated when the physician is unsure of the diagnosis or feels unable to provide recommended treatment.

Patients are more likely to accept the concept of a psychiatric referral if this possibility has been broached at the time of initial diagnosis, or early in the course of treatment. Patients should be helped to understand that a request for psychiatric or mental health assessment is simply a matter of obtaining another professional opinion. Drawing the anal- ogy of referrals made to specialists in other fields of medicine, e.g., cardiology or gastroenterology, reduces the likelihood that patients will feel aban- doned, blamed, or dismissed.

Explain that consultation involves assessment by an expert who will advise the primary care physician on appropriate management strategies. This mental health specialist who may be another physician, a psychologist, advanced practice nurse, or social worker. After the consultant interviews the patient, gathers information, and makes suggestions, the patient will see his/her own physician again to decide on further treatment [40].

M A N A G E M E N T S T R A T E G I E S

Depression can almost always be treated successfully, either with medication, psychotherapy, or a combination of both: Not all patients respond to the same therapy. However, a patient who fails to respond to the first treatment is likely to respond to a change in strategy. Management depends largely on the severity of functional impairment. Realistic goals can be set when patient preferences are respected.

Major Depression Research demonstrates that mild to moderate forms of major depression respond equally well to psychotherapy or pharmacotherapy. However, more severe forms of major depression should be treated with pharmacotherapy. A combination of pharmacotherapy and psychotherapy may be superior to either approach alone for patients with severe, chronic, or recurrent forms of depression [41]. Com- bination therapy may also prove particularly useful for patients with significant psychosocial problems.

Chronic Depression Recent studies indicate that antidepressant medications are also effective for chronic depression. Psy-

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chotherapy may also be valuable, but efficacy studies are limited. Untreated dysthymia can be very frustrating to manage because of its somatic presentation, chronicity, and tenacious symptoms. Re- ferral to an expert should be considered for patients who do not improve after initial management efforts.

Minor Depression

Since most cases of minor depression are self- limiting, a period of 1-2 months of watchful waiting may be sufficient for patients with mild impairment. If symptoms do not improve or impairment continues, regular supportive visits with the physician may be beneficial. Patients with moderate or severe impairment should probably receive active treatment or referral for mental health consultation. Anecdotal experience suggests that either psychotherapy or a cautious trial of antidepressant medication may be beneficial.

P H A R M A C O T H E R A P Y

Efficacious antidepressants have been available for over 40 years, but many new agents now offer the advantages of fewer side effects and greater ease of use, resulting in increased adherence by patients [42].

Although the tricyclic antidepressants (TCAs) can be considered a standard of treatment efficacy, they are associated with a host of troubling side effects, such as anticholinergic (dry mouth, constipation, urinary retention), antihistaminic (sedation), antiadrenergic (postural hypotension), and cardiac (quinidine-like delayed conduction). Due to a low therapeutic index, they can be lethal in overdose.

Among numerous tricyclics available, two of the more useful agents are nortriptyline (Pamelor, Aventyl) and desipramine (Norpramin). Nortripty- line has an established therapeutic window (blood level) with relatively less postural hypotension than other tricyclics, and desipramine (Norpramin) has the lowest level of anticholinergic side effects of the tricyclics [1].

In the late 1980s, a selective serotonin reuptake inhibitor (SSRI), fluoxetine (Prozac), heralded a new era in the pharmacotherapy of depression. For the first time, an agent with a relatively benign side-effect profile became available for the treatment of depression. As of 1998, more than 25 mil- li0n individuals throughout the world had been

treated with fluoxetine. Eight other new agents have now been introduced in the United States (U.S.).

Three of these eight are other SSRIs, citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft). Other new agents, bupropion (Wellbutrin), mirtazapine (Remeron), nefazodone (Serzone), rebox- irene (Vestra) and venlafaxine (Effexor) are equally efficacious but have different mechanisms of action and side-effect profiles. [See Section 13: Table of Antidepressants, p. 354.]

In comparison to the tricyclics, all nine new antidepressants are relatively free of dangerous side effects, not lethal in overdose (when not combined with other medications), and are, for the most part, better tolerated. Despite higher per unit costs of new agents, overall cost-efficacy is similar to or better than tricyclics [43]. New agents cause fewer side effects, have low toxicity, probably improve patient adherence, and require fewer physician follow-up visits to titrate doses and monitor side effects.

Most of the common side effects of SSRIs, including agitation, gastrointestinal distress, and insomnia, occur in less than 20% of patients and rarely require discontinuation. Sexual dysfunction (de- creased libido or difficulty reaching orgasm) probably occurs in more than 30% of patients and may lead to significant impairment in quality of life or nonadherence. Despite the small incidence of agitation or insomnia, these agents can be used in depressed patients with insomnia since SSRIs usually lead to improved sleep within 2 to 3 weeks.

SSRIs should be started in lower doses for patients complaining of anxiety or panic attacks, as the initial agitation may make the patient extremely uncomfortable. Anxiety or insomnia associated with SSRIs may require treatment with small doses of a sedating antidepressant or a benzodiazepine for a short period of time. These adjunctive medications can usually be stopped as the depression remits.

Side effects of venlafaxine and bupropion are similar to the SSRIs, but slightly different in prevalence. Bupropion does not cause sexual dysfunction. There is some evidence that higher dose venlafaxine may be more effective than SSRIs, especially for hospitalized, very severe, or treatment-refractory depression. However, in doses above 300 mg, venlafaxine can cause persistent blood pressure elevation in about 10% of patients. Bupropion, in doses greater than 450 mg a day is associated with increased risk of seizures and

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should not be used in patients with seizure disorders. No single dose should ex.ceed 150 mg. Both venlafaxine and bupropion are now available in extended or sustained release formulations, which

simplify daily dosing. Nefazodone (Serzone) is a weak blocker of sero-

tonin reuptake while it also blocks the 5-HT 2 receptor post-synaptically. It is more sedating than pure SSRIs and does not cause sexual side effects. Be- cause of its anxiolytic effects, it can often be used as monotherapy for patients with depression and significant anxiety. Sleep EEGs indicate that this agent restores natural sleep as the depression remits and has a superior effect on measures of insomnia compared to SSRIs.

Mirtazapine (Remeron) blocks several serotonin receptors and alpha (2)-adrenergic receptors. The blockade of alpha (2)-adrenergic receptors increases available norepinephrine and serotonin, although it does not inhibit reuptake. Mirtazapine does not block muscarinic acetylcholine or alpha (1)- adrenergic receptors. As with all new antidepressants, efficacy seems equal to previous agents, but with fewer side effects than TCAS. Mirtazapine produces minimal anticholinergic symptoms, promotes sleep, and reduces agitation. It does not cause postural hypotension or hypertension, and is relatively safe in overdose. Its major drawbacks are daytime sedation and weight gain, associated with histamine receptor blockade. The Physician's Desk Reference (PDR) warns of an extremely rare risk of agranulocytosis.

Reboxitene (Vestra) is a selective norepinephrine reuptake inhibitor released in Europe and expected to be approved for use in the U.S. in 2001. Rebox- itene provides a safer alternative to noradrenergic TCAs such as desipramine and nortriptyline. Some evidence suggests that this norepinephrine selective drug may have a particularly useful effect on aspects of social adjustment and, when compared to SSRIs, a stronger antidepressant effect for patients with more severe depression.

Sedation and insomnia, common side effects of many antidepressants usually remit within a few weeks. Persistent effects may require dose reduction. Dosing at bedtime is useful for sedation; dosing in the morning is preferred if patients complain of insomnia. Dose reduction or adjunctive sedating or anxiolytic agents may be necessary for side- effects of tachycardia, agitation, or tremor.

Drugs that block the muscarinic acetylcholine receptors cause blurred vision, dry mouth, urinary hesitancy/retention, and constipation. Bulk laxa-

tives and extra fluids may decrease constipation. Dry mouth, which occurs with many antidepressants, may respond to artificial saliva preparations. Potent anticholinergic agents may also produce central effects, such as disorientation, impaired memory, confusion, and hallucinations: In such cases, the medication must be stopped immediately.

Postural hypotension is a common and dangerous adverse effect of TCAs. Newer antidepressants are much less likely to cause this problem. Check the patient's EKG and assess cardiac conduction before giving TCAs because these agents cause significant cardiac conduction delay. Patients on TCAs with ischemic heart disease also are at risk for ven- tricular arrhythmias. Rare sudden cardiac death has been reported.

Between 30-60% of patients on SSRIs complain of sexual dysfunction (mainly ejaculatory/erectile problems in men and anorgasmia in women). This does not generally occur with bupropion, mirtazapine, or nefazodone.

No single drug has been ~reliably effective for sexual dysfunction caused by SSRIs. Though the mechanism of action is uncertain for SSRI-induced sexual dysfunction, sildenafil (Viagra) may prove to be effective for m e n with erectile or ejaculatory dysfunction and for women with anorgasmia. Al- though the addition of yohimbine or bupropion has been used for this condition, they are not always effective. For some patients, another antidepressant may be necessary to remedy sexual dysfunction.

Abruptly stopping tricyclics may cause mild withdrawal symptoms such as diarrhea, cramps, agitation, and insomnia. Abrupt discontinuation of the shorter-acting SSRIs (i.e. all SSRIs with the exception of fluoxetine) and venlafaxine is also associated with agitation, nausea, tremors, and dyspho- ria. Therefore, it is best to stop these drugs gradually to minimize withdrawal [44].

Drug Interactions (Cytochrome P450)

Potential interactions between antidepressants and other medications can have an impact upon drug efficacy and lead to dangerous physical effects. Most drug interactions involving antidepressants result from effects on the cytochrome P-450 hepatic isoenzymes, in particular the 2D6 and 3A4 sub- systems. Many antidepressants inhibit these en- zymes, resulting in altered metabolism of other medications [45].

Patients at highest risk for drug interactions are

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the elderly, debilitated, those already taking multiple medications, and patients with significant hepatic or renal disease. Obtain a careful drug history before initiating antidepressant therapy. Adding an antidepressant to other drugs may lead to lack of efficacy or significant toxicity of any of the agents.

Physicians should be cautious when prescribing antidepressants to patients on any other agent. Known interactions of consequence may occur with coumadin, digoxin, anticonvulsants, tricyclics, erythromycin, ketaconazole, alprazolam, codeine, dextromethoraphan, beta blockers, calcium channel blockers, and type 1C antiarrhythmic agents. Begin the antidepressant at a low dose, carefully observe clinical effects, and monitor serum drug levels. Drug information services and pharmacies can provide reliable Prescribing information. Drug interactions can also be found free of charge on the Internet at PHYSICIANS ON LINE.COM (www. physiciansonline.com).

There are some important variations among antidepressants. Drugs metabolized by 2D6 include tricyclic antidepressants, type 1C antiarrhythmics, beta:blockers, narcotics, codeine, dextromethoraphan, and several neuroleptics. Among the SSRIs, paroxetine and fluoxetine have the greatest inhibitory effect on the 2D6 system. Sertraline has minimal effects at low doses, but an inhibitory effect may emerge with doses above 150 mg. Citalopram, like sertraline, has relatively low effects on the 2D6 system. The other new (non-SSRI) antidepressants have little or no 2D6 effect, with the exception of bupropion, which has a modest inhibitory effect on 2D6.

Nefazodone and norfluoxetine (the metabolite of fluoxetine) are potent inhibitors of the 3A4 system. This warrants caution in the use of drugs metabolized by 3A4, including calcium channel blockers, erythromycin, ketaconazole, and alprazolam. The metabolism of coumadin, digoxin, and some anti- convulsantd can be inhibited by antidepressants. Blood levels and bleeding times should be checked regularly.

Patient Follow Up

While all depressed patients need regularly scheduled appointments, it is especially important for those who have initially been prescribed an antidepressant. The physician should see the patient within 2 weeks to monitor effects of the medication, to check for adherence to the treatment plan, and to offer support as necessary. Patient response can

best be evaluated approximately 6 weeks after reaching a therapeutic dose of the agent. Maximum therapeutic dosages should be prescribed before considering an antidepressant to be a failure. [See Section 13: Table of Antidepressants, p. 354.]

Outcome assessment instruments can help to evaluate patient response. An increased dose or new medication may be indicated if the original agent is insufficient. After an adequate response to antidepressant therapy is achieved, the patient should be re-evaluated in 4 -6 weeks to insure that remission has been sustained. Expert consultation may be appropriate at this time if the treatment response is unsatisfactory.

Physician encouragement is particularly important in the interval between beginning treatment and evaluating outcome. The hopelessness that ac- companies depression can interfere with the patient's ability to note improvement, although progress may be apparent to others. In the absence of support by the physician and significant others, depressed patients can embraCe a perceived lack of progress as further evidence of their inadequacy. Discouragement only exacerbates their hopelessness, reinforces feelings of personal failure, and may trigger or aggravate noncompliance to treatment strategies.

PSYCHOLOGIC APPROACHES

Pafients with minor depression, chronic depression, and mild to moderate major depression may benefit from psychotherapy. Cognitive behavioral therapy and interpersorial therapy have proven effective for the treatment of major depression. These therapies are fime-limited, focused on current functioning, and directed toward adaptation rather than personality change. The efficacy of long-term, insight-oriented psychotherapy for major depression is not known. Therefore, this therapy is not recommended as a first-line treatment for major depression.

While supportive office counseling by the pri- m a r y care practitioner has never been empirically tested, many physicians treating depression com- bine this intervention with pharmacotherapy with seemingly beneficial results.

Cognitive Behavioral Therapy. Many depressed patients habitually view themselves, the world, and the future with pronounced negativism. Cognitive behavioral therapy focuses on revising maladaptive

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processes of thinking, perceptions, attitudes, and beliefs. Emphasis is placed on identifying positive experiences, experimenting with new behaviors, and gradually progressing to more difficult situations. By challenging negative interpretations and reinforcing positive experiences, the therapist facilitates internalization of a more positive outlook on life. This approach also encourages the depressed patient to increase pleasant activities and become more socially active.

Interpersonal Therapy. Interpersonal conflict and social isolation can be associated with depression. Interpersonal therapy is a time-limited approach aimed at clarification of interpersonal difficulties, such as role disputes, prolonged grief reactions, or role transitions. The therapist and patient define the nature of the problem, identify so- lutions, and utilize skills to reach a resolution.

Supportive Office Counseling. Supportive office counseling is based on empathic listening to patients' perceptions of life stresses. It focuses on managing current difficulties with emphasis on the patient's strengths and available resources. Dis- cussing practical approaches to daily living can simply be a matter of making common sense suggestions by discouraging patients from assuming new stresses, and encouraging them to engage in pleasurable activities. Reiterate that negative thinking passes as depression improves. Patients should be encouraged to increase contact with family, friends, and community groups to benefit from social support.

The mnemonic "SPEAK" was created by John Christensen as an aid for primary care physicians in their psychotherapeutic role with depressed patients. The five-step tool provides a pragmatic and structured approach to brief office counseling of patients that goes beyond, but complements, the non-specific BATHE technique [46].

• "S" stands for "schedule" each day. Depressed patients find it difficult to activate themselves. Physicians can ask patients to actually prepare a written daily schedule for themselves. This will help motivate and activate depressed patients.

• "P" indicates that physicians should encourage their depressed patients to include at least one "pleasant" event in their daily schedule.

• "E" stands for "exercise," which has been shown to be helpful for the relief of depressive symptoms.

• "A" stands for "assertion." Since many depressed patients lose their self-confidence, physicians can encourage them to assume more control in their daily lives and regain their previous sense of self-reliance. However, care should be taken to encourage adaptive assertiveness and not maladaptive expression of anger.

• "K" stands for thinking "kind" thoughts a b o u t oneself. Depressed patients usually see the worst in themselves. Physicians can encourage patients by pointing out positive coping abilities and strengths.

A TOOL-KIT FOR PRIMARY CARE

The MacArthur Foundation Depression Education Program includes a "tool kit" to assist physicians screen patients for depression, make a diagnosis, and monitor outcomes.

1. Patient-Administered Instrument: Patient Health Questionnaire (PHQ)

The PRIME-M.D. Patient Health Questionnaire (PHQ) 3 as been chosen as the core patient- administered screening, diagnostic, and outcome- monitoring tool of this program [47]. In a multi- center study of eight family practice and internal medicine sites with 3000 patients and 62 physicians, the instrument was found to have 73% sensitivity and 98% specificity for the diagnosis of major depression [47]. The instrument was well accepted by patients and physicians, and required very little physician time to review (less than I min for 42% of patients and 1-2 min for another 43% of patients). Patients diagnosed with mental disorders on this instrument Suffered from significantly more functional impairment and disability and utilized significantly more medical care than patients without mental disorders.

Many experts now recommend that depression screening instruments be reserved for those patients in high-risk groups (e.g. patients with disabling chronic diseases, sleep complaInts, unex- plained or ill-defined pain or other symptoms, history of prior psYchiatric illness, headaches, or sad mood or anhedonia). The PHQ can also be administered on regular follow-up visits to monitor response to treatment. 3

3 PHQ copyright held by Pfizer, Inc., but it may be photocopied ad libitum. The PHQ tool in this workbook has been modified by David Brody, M.D.

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2. Physician-Administered Instrument: DSM-IV Interview Checklist

Clinicians should not rely exclusively on the P H Q to establish a depress ion diagnosis and moni tor outcome. Rather, PHQ results should be confirmed by a clinical interview before initiating t reatment and to monitor t reatment outcome. The DSM-IV Interview Checklist and the Depression Outcome Monitor were developed for this p rogram and provide structure to facilitate these confi rmatory processes.

CONCLUSION

Depression is a medical disorder commonly seen in primary care. Effective t reatment of depression requires a compassionate approach, skillful care, long-term follow up, and sometimes, active pharmacotherapy Bolstered by a positive att i tude toward its diagnosis and management , effective communication skills, and appropr ia te expert backup, the primary care practit ioner can feel confident in the assessment and management of this highly treatable disorder.

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33. White J, Levinson W, Roter D: "Oh, by the w a y . . . ": the closing moments of the medical visit. J Gen Intern Med 9:24-28, 1994

34. Cohen-Cole SA, Brown FW, McDaniel JS: Assessment of depression and grief reactions in the medically ill. A. Stoudemire, B Fogel (eds), Psychiatric Care of the Medical Patient. New York, Oxford University Press, 1993

35. Cole S, Bird J: The Medical Interview. The Three- Function Approach/(Second Edition): St. Louis, MO, Mosby, 2000.

36. Cohen-Cole SA, Mance R: Evaluating the suicidal patient. In M Lipkin, S Putnam, A Lazare (eds), The Medical Interview: Clinical Care, Education, and Re- search. New York, Springer-Verlag, 1998

37. Stuart MR: The BATHE Technique. In RE Rake! (ed), Saunders Manual of Medical Practice. Philadelphia, PA, W.B. Saunders, 1996.

38. Gordon GH, Duffy FD: Educating and enlisting patients. J Clin Outcomes Management 5:1-6, 1998

39. Lin E, Von Korff M, Katon W, et ah The role of the primary care physician behavior and patient's adherence to antidepressant therapy: Med Care 33:67-74, 1995

40. Bursztajn H, Barsky AJ: Facilitating patient acceptance of a psychiatric referral. Arch Intern Med 1544- 1548, 1983

41. Schulberg HC, Katon WJ, Simon GE, Rush AJ: Best clinical practice: guidelines for managing major depression In primary medical care. J Clin Psychiatry 60(suppl 7):19-26, 1999

42. Janicak PG, Davis J, Preskorn SH, Ayd FJ Jr: Princi- ples and Practice of Psychopharmacology (Second edition). Baltimore, Williams and Wilkins, 1997

43. Sclar D, Skaer T, Robison L, et al: Economic outcomes with antidepressant pharmacotherapy: a retrospec- tive intent-to-treat analysis. J Clin Psychiatry 59(suppl 2):13,17, 1998

44. Kaplan HI, Sadock BJ: Kaplan and Sadock's Synopsis of Psychiatry (Eighth Edition). Baltimore, Williams and Wilkins, 1998

45. Jefferson J: Drug and diet interactions: avoiding therapeutic paralysis. J Clin Psychiatry 59(suppl 16):31- 39, 1998

46. Cole S, Christensen FJ, Raju Met al: Depression. In M Feldman, J Christensen (eds), Behavioral Medicine in Primary Care. Stamford, CT, Appleton & Lange, 1997

47. Spitzer RL, Kroenke K, Williams JBW: Validation and utility of a self-report version of PRIME-M.D: The PHQ Primary Care Study. JAMA 82:1737-1744, 1999

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SECTION 10: AGENDA: SESSION II

7:30 AM Registration

8:00

8:30

9:00

10:30

General Discussion • C h a n g e s in pract ice resul t ing f r o m

Session I • Pa t ien t r e sponses • Phys ic i an react ions

Review Objectives

Skills Workshop • A u d i o t a p e r ev i ew • Skills pract ice

Break

10:45

11:30

12:00 VM

Psychopharmacology Practicum • L e c t u r e / d i s c u s s i o n • O u t c o m e s m a n a g e m e n t cases

Conclusion • S u m m a r y • Persona l p l a n s / c o m m i t m e n t for

c h a n g e

Adjournment • Eva lua t ions • Sugges t ions for fu tu re p r o g r a m s • L u n c h

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SECTION 11: LECTURE GUIDE 2: SLIDE PRESENTATION

Notes t,l~l.J,l,S "

PRACTICAL ANTIDEPRESSANT

PSYCHOPHARMACOLOGY

Session I I

TREATMENT SELECTION FOR DEPRESSION

MINOR MAJOR MAJOR CHRONIC (MILD/MOD) (SEVERE)

SUPPORT/ + + + + IOFFICE COUNSELING

MEDICATION ?~ MONOTHERAPY PRIMARY PRIM.4JIY acceptable

PSYCHOTHERAPY ? MONOTHERAPY ADJUNCT ADJUNCT acceptable

tlJ,,I,tl, i

M E D I C A T I O N A L G O R I T H M

, Start with SSRI or appropriate new agent

• Increase every 2-4 weeks prn

• If no response, switch agents

• If partial response at maximum dose, consider augmentation or consultation

¢IYITN :

E Ih-

ill ill

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M A N A G I N G S I D E E F F E C T S

• Agitat ion/Insomnia • Use adjunctive sedating agent • Switch to mirtazapine,, nefazodone

• Sexual dysfunction • Switch to bupropion, mirtazapine,

nefazodone • Add bupropion' sildenafil,

yohimbme

Notes

(continued)

• GI distress • Give medication after meals

• Sedation • Give medication HS

• Antichol inergic effects • Bulk in diet, sugarless lemon drops

• Pos tu ra l hypotension • Hydration, change position slowly,

support hose

flTtTl

C O M O R B I D A N X I E T Y / P A N I C

• Effucate patient • Give low dose SSRI, titrate slowly • Consider benzodiazepine • Use buspirone for anxiety; not for

panic • Consider nefazodone,

mirtazapine, or venlafaxine monotherapy

(ITI;Ii

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t,~lJ, I,J W H E N D O Y O U S T O P ?

• M a i n t a i n dose 4-9 m o n t h s a f t e r remission

• Chance of relapse • 50% if 1 prior episode. • 75% if 2 prior episodes • 90% if 3 prior episodes

• Patient may need lifetime therapy • Maintenance should be full dose

I'tTITti

Notes

t,W~l) DOSING SSl~s

• Start ing doses: • Citalopram (Cele×a) 20rag • Fluoxetine (Prozac) 20rag • Paroxetine (Paxil) 20rag • Sertraline (Zoloft) 50rag

• Star t with a half dose for anxious, ,. elderly, or medically ill patients

• Increase dose every 2-4 weeks prn

i'tTITIi

. b up rOcTHnER(wNelEIbWut rA~ ENTS Start at 100 mg bid or 150 mg (SR)

: Increase dose every 2-4 weeks pm • Do not use in patients at risk for

seizures or bulemia • Do not exceed 150rag in one dose

• mirtazapine (Remeron) • Start at 15rag/night • Increase dose every 2-4 weeks pm

~ITITh

350

The MacArthur Foundat ion Depression Education Program for Pr imary Care Physicians

/ Nil* nefazodone (Serzone) lll/ /1111 : start at 50mgbid 111/ LIlII Titrate to therapeutic level (>400mg) lilt t:~] as sedation decreases ~: [~[* venlafaxine (Effexor) lilll : Start at 37.5mg bid or 75 mg (XR) tiil [IJi] Increase dose every 2-4 weeks prn llil II1[I • Elevated BP in 10% of patients with IIII

Notes

GA~,b DOSING TCAs

• nortriptyline (Pamelor, Aventyl) • Start at 25mg each night • Increase by 25mg weekly • Effective dose range 50-150mg • Use therapeutic window to titrate

• desipramine (Norpramin) • Start at 50mg each morning • Increase by 50mg weekly • Effective dose range 150-300mg • Monitor blood levels

¢lYIYrl

t.l,kl~l) DRUG I N T E R A C T I O N S

(ANTIDEPRESSANT INHIBITION OF CYTOCHROME P450)

• IiD6 • Moderate inhibition (fluoxetine,

paroxetine) • Low inhibition (ci taiopram, sertraline)

• Low inhibtion (other new agents) • IIIA3/4

• use nefazodone with caution

¢tYIYN

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S. Cole et al.

t,IJ,,I,tlJ ' U S E C A U T I O N W I T H :

• COUMADIN • DIGOXIN • ANTICONVULSANTS • ERTHYROMYCIN • KETACONAZOLE • ALPRAZOLAM • CODEINE • DEXTROMETHORAPHAN • BETA/CALCIUM CHANNEL BLOCKERS • TYPE IC ANTIARRHYTHMIC AGENTS

Notes

rIYIYt~

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SECTION 12: O U T C O M E S M A N A G E M E N T CASES

1. Two weeks ago, you started a 60-year-old female with diabetes on nortriptyline (Pamelor) 50 mg hs. She now complains of lightheartedness when she stands up. What should you do?

2. After three days of treatment, this 30-year-old female on fluoxetine (Prozac) 20 mg a day complains of agitation and insomnia. What do you do?

3. This 70-year-old male complains of sedation on nefazodone (Serzone) 150 mg bid. What do you do now? 4. What should you do when a 30-year-old female complains of anorgasmia on sertraline (Zoloft) 100 mg

a day? 5. This 40-year-old male reports moderate improvement after 2 weeks on paroxetine (Paxil) 20 mg a day.

Whht do you do next? 6. After 8 weeks on venlafaxine (Effexor) 150 mg bid, this patient is considerably better, but not back to

baseline. What do you do? 7. This 40-year-old female is back to baseline functioning after 3 months on desipramine (Norpramin)

150 mg a day. She has no side effects and has started to decrease the dose because she feels fine. What should you do?

8. This elderly male regained full functioning after taking citalopram (Celexa) 20 mg each morning. After 6 months, he is complaining of insomnia and depressive feelings again. What do you do now?

9. A female nursing home patient with major depression is taking digoxin, coumadin, and carbarnazepine. Which antidepressant would you use and why?

10. You decide to start antidepressants for a 30-year-old female who has major depression, panic attacks, and significant anxiety. Which medication(s) would you use and how?

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SECTION 13: TABLE OF ANTIDEPRESSANTS: SIDE EFFECTS, MECHANISMS OF ACTION, DOSAGES

A C h Other Antidepressants Sedation Blockade Orthostasis SRI NRI Activity Dosage

Tricyclics Amitriptyline (Elavil) + + + + + + + + + + + + 0 75-300 mg Desipramine (Norpramin) + + + 0 + + + 0 75-250 mg Doxepin (Sinequan) + + + + + + + + + + + + 0 75-300 mg Imipramine (Tofranil) + + + + + + + + + + 0 75-300 mg Nortriptyline (Pamelor) + + + + + + + + + 0 50-150 mg

SSRIs Citalopram (Celexa) 0 0 0 + + + 0 0 20-40 mg Fluoxetine (Prozac) 0 0 0 + + + 0 0 20-80 mg Paroxetine (Paxil) + + 0 + + + 0 0 20-50 mg Sertr~line (Zoloft) 0 0 0 + + + 0 0 50-200 mg

Other New Agents Brup rop ion (Wellbutrin) 0 0 0 0 + DA/NE* 150-450 mg Mirtazapine (Remeron) + + + 0 0 0 0 ** 15-45 mg Nefazodone (Serzone) + + 0 0 + 0 / + 5-HT2A*** 300-600 mg Reboxitene (Vestra) 0 0 + 0 + + + 0 8-10 mg Venlafaxine (Effexor) 0 0 0 + + + + + 0 75-375 mg

0, None; +, Slight; ++, Moderate; +++, Marked. SRI, serotonin re-uptake inhibition; NRI, norepinephrine re-uptake inhibition; *DA/NE, dopaminergic/noradrenergic activity

**blockade of aaNE, 5HT2A, 5-HT2c, and 5-HT 3 receptors ***blockade of 5-HT2A receptors © The John D. and Catherine T. MacArthur Foundation, 1998. Reprinted with permission.

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S E C T I O N 14: C O N S U L T A N T S

Family Physicians Thomas Campbell, M.D. Associate Professor of Family Medicine

and Psychiatry University of Rochester School of Medicine

Forrest Lang, M.D. Professor of Family Medicine James H. Quillen College of Medicine East Tennessee State University

Mary Elizabeth Roth, M.D. Chair, Department of Family Practice Providence Hospital, Michigan

A. Patrick Jonas, M.D. Family Physician in Private Practice Beavercreek, Ohio

Internists Geoff Gordon, M.D. Associate Director Education and Research Bayer Institute for Healthcare Communication

Dennis Novack, M.D. Professor of Medicine Medical College Hospitals Philadelphia, Pennsylvania

Arthur Rift<in, M.D. Director, Mental Retardation/Developmental

Disabilities Service Hillside Hospital, New York Michael Thase, M.D. Professor of Psychiatry University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic,

Pittsburgh Joseph Weiner, M.D., Ph.D. Training Director, Primary Care=Psychiatry

Program Hillside Hospital, NY

Other Expert Consultants

Kathryn Rost, Ph.D. Scientific Director, NIMH Center for Mental Health Service Research University of Arkansas for Medical Services Little Rock, Arkansas Debra Roter, DrPH Professor, John Hopkins School of Hygiene and

Public Health Baltimore, Maryland

A C K N O W L E D G M E N T S

Psychiatrists Donald Fidler, M.D. Associate Professor of Psychiatry West Virginia University School of Medicine

Wayne Katon, M.D. Professor of Psychiatry University of Washington School of Medicine,

Seattle

Alan Mendetowicz M.D. Associate Professor of Psychiatry Albert Einstein College of Medicine, New York

Philip Muskin, M.D. Assistant Chief, C-L Psychiatry Columbia Presbyterian Medical Center, New York

The authors of this program gratefully thank all of the consultants who generously contributed their time and effort to help develop the curriculum of The MacArthur Foundation Depression Education Program for Primary Care Physicians. Their input and suggestions have had a positive impact on the quality of this initiative. In particular, we would like to express our appreciation to Geoff Gordon, Philip Muskin, and Arthur Rifkin for their excellent contributions to the monograph. Don Fidler de- serves special mention for his help in writing and participating in the videotape demonstration. We also thank Shella Ilani, for her help as Project Co- ordinator and Rosetta Maretta and Deidre Willin for their administrative assistance.

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S. Cole et al.


F A C I L I T A T O R ' S G U I D E : S E S S I O N I

Before the Workshop Send letters of invitation describing program. Instruct participants to read the monograph before Session I.

7:30 AM Registration/Breakfast

8:00 Introduction Set the tone for an interactive and learner-centered workshop:

One facilitator takes the lead for this segment with a brief personal introduction and explanation of the program. The other facilitator then introduces himself/herself. (5 minutes) The lead facilitator distributes 3×5 cards and asks all participants to note three personal learning objectives for this workshop. (5 minutes) The lead facilitator asks participants to introduce themselves, describe their current work situations, and state their personal learning objectives. The other facilitator si- multaneously lists objectives on a flip chart. (10 minutes) The lead facilitator summarizes partici~ pants' objectives and asks them to com- pare their list with those described in Sec- tiori 1. Past experience shows that learners' and program objectives are usually similar. If there are significant differences, facilitators then discuss how the workshop can (or cannot) be tailored to meet the participants' specific learning objectives. (5 minutes) ~ The lead facilitator briefly reviews the program structure and workbook. Learners should read the monograph, after Session 1, if they have not already done so. (5 minutes)

8:30 Lecture With Discussion Organize lecture with supporting slides to meet the participants" and program's knowledge objectives. In addition, lecturers should mention the following:

Questions for clarification are invited throughout the presentation. However, two "stop" points have been incorporated into the agenda to facilitate open-ended discussion. Psychopharmacology presented in Session I provides an overview of antidepressant medications and appropriate treatment strategies. However, there will be a more detailed presentation of pharmacotherapy in Session II, along with case studies for additional discussion. A table on the use of antidepressant medications has been provided in the participants" workbook (at the end of the monograph and Section 13) and on a pocketsize card. Outcomes monitoring is essential. As such, a tool kit for office use to assist in diagnosis and management of outcomes has also been provided in the participants' workbook (Section 7). An interactive format is encouraged. The formal presentation should be completed after 60 minutes, to allow for 15 minutes of open discussion. (75 minutes total)

9:45 Break

10:00 Skills Workshop Interview Checklist/Video (10:00-10:45)

A facilitator should present rationale for the focus on communication skills and cor- relate with lecture material. (5 minutes) Review interviewing skills on the checklist in Section 4. (10 minutes) Introduce the videotape demonstration of a 15-minute interview between a physi-

356


cian and a non-adherent diabetic. The patient who presents with a chief complaint of stomach pain is also suffering from covert depression. ADDENDUM: Make it very clear to participants that the videotape demonstrates a wide range of skills that may be relevant to a complicated primary care patient encounter. In reality, most primary care visits will be shorter than the interview on the videotape. (15 minutes) Ask participants to use the interview checklist to rate communication skills demonstrated in the video. Elicit participants' reactions to the interaction. Con- sider ways through which the dialogue may have been improved through more effective communication techniques. (15 minutes)

~kills Practice (10:45-11:30)

Present the process of "SPAR" (Section 5) to structure role-play exercises. Place em-

,~phasis on specific feedback and repetition. (5 minutes) Facilitators now lead a role-play exercise (using SPAR). Select one participant to be "the patient" and another the "doctor." The demonstration should repeat the challenge of treating a non-adherent, resistant patient with depression. (20 minutes)

Divide learners into groups of two mem- bers each for the final 20 minutes of the workshop. One participant should play the role of physician and the other plays the patient. The "patient" must give the "physician" feedback, and then the segment should be repeated. Learners then switch roles.

If participants prefer to practice a different scenario, an additional role-play case is in the handbook (Section 6). Facilitators circulate among groups to help guide this process, provide instruction, and offer additional feedback. (20 minutes)

11:30 Summary and Conclusion Participants will convene in the group as a whole to discuss the results of small group practice, to summarize the workshop, to explain the interces- sion audiotape exercise, and to discuss outcomes tools.

Elicit comments and reactions to the skills practice. One facilitator summarizes the morning's experiences, while reviewing knowledge and skills objectives. Give instructions for obtaining audiotapes. Discuss the use of screening and outcomes instruments in the toolkit.

12:00 Evaluation and Adjournment

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FACILITATOR'S GUIDE: S E S S I O N II

Before the Workshop Call physicians to identify and overcome barriers to obtaining audiotapes. Remind participants to read monograph.

7:30 AM Registration/Breakfast

8:00 General Discussion/Impact of Session I Participants discuss the impact of training from Session I on their patients and on their clinical practices.,

Welcome and distribute 3x5 cards and ask participants to write down: 1) the ways they have changed their practices based on Session 1; and 2) their personal learning objectives for Session 2. (5 minutes) Participants re-introduce themselves and report the ways their practices have changed and their personal learning objectives. One facilitator leads discussion; the other writes new objectives on flip chart. (15 minutes) Discuss agenda and learning objectives for Session II based upon above exercise. (10 minutes)

8:30 Review Objectives Summarize participants' written evaluations from Session I. Evaluate the extent to which objectives were adequately met, provide focused education, and set goals for Session II. (30 minutes)

9:00 Skills Workshop One participant presents a 5-minute au-

diotape segment in the large group for discussion, feedback, and skills practice. (30 minutes) Participants break int O groups of three for audiotape feedback. Learners have 15 minutes each to play their tapes, obtain feedback from colleagues, and practice new interventions through role-play. Fa- cilitators circulate to encourage practice with feedback and repetition. (45 minutes) Participants reconvene to discuss small group experiences. (15 minutes)

10:30 Break

10:45 Psychopharmacology Practicum Present a lecture on pragmatic psycho-

pharmacology for primary care providers. (30 minutes) Practice and discuss psychopharmacology outcomes management using specific case examples. (15 minutes)

11:30 Conclusion Summarize results of Session II. Ask participants for suggestions to make the program more meaningful. Elicit statements about what specific changes learners plan to make in clinical practice as a result of the workshops. (30 minutes)

12:00 Evaluation and Adjournment

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Documents

The MacArthur foundation depression education program for primary care physicians: background, participant's workbook, and facilitator's guide